Effect of Pre‐Hospital Workflow Optimization on Treatment Delays and Clinical Outcomes in Acute Ischemic Stroke: A Systematic Review and Meta‐Analysis

 But since you don't know how fast you have to deliver either tPA, IVT or mechanical thrombectomy to get 100% recovery, you haven't moved the needle one iota closer to solving stroke.  Please step aside and let better people than you actually solve stroke. You are playing around the edges.

Effect of Pre‐Hospital Workflow Optimization on Treatment Delays and Clinical Outcomes in Acute Ischemic Stroke: A Systematic Review and Meta‐Analysis

Seemub Zaman Chowdhury

Prithvi Santana Baskar

Sonu Bhaskar

First published: 02 January 2021

https://doi.org/10.1111/acem.14204

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/acem.14204

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Abstract

Background

The prehospital phase is critical in ensuring that stroke treatment is delivered quickly and is a major source of time delay. This study sought to identify and examine Pre‐Hospital Stroke Workflow Optimizations (PSWO) and their impact on improving health systems, reperfusion rates, treatment delays, and clinical outcomes.

Methods

The authors conducted a systematic literature review and meta‐analysis by extracting data from several research databases (PubMed, Cochrane, Medline, and Embase) published since 2005. We used appropriate key search terms to identify clinical studies concerning prehospital workflow optimization, following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines.

Results

The Authors identified 27 articles that looked at the impact of pre‐hospital workflow optimizations on time and treatment parameters, 26 were included in the meta‐analysis. The PSWO were sub‐grouped into 3 categories: Improved Intravenous Thrombolysis (IVT) Triage, Large Vessel Occlusion (LVO) bypass, and Mobile Stroke Unit (MSU). The salient findings are: Improved IVT Triage led to significantly improved rates of IVT (RR=1.80; 95% CI, 1.18–2.75); however, MSU did not (RR=1.22; 95% CI, 0.98–1.52). Improved IVT Triage (SMD=‐0.82; 95% CI, ‐1.32 – ‐0.32), LVO bypass (SMD=‐0.80; 95% CI, ‐1.13– ‐0.47) and MSU (SMD=‐0.87; 95% CI, ‐1.57 – ‐0.17) were found to significantly reduce door to needle time for IVT. MSU was found to significantly reduce call to needle (SMD=‐1.41; 95% CI, ‐1.94 – ‐0.88) and onset to needle (SMD= ‐1.15; 95% CI, ‐1.74– ‐0.56) times for IVT. MSU additionally demonstrated significant reduction in door to perfusion (SMD= ‐0.72; 95% CI, ‐1.32 – ‐0.12) as well as call to perfusion (SMD= ‐0.73; 95% CI, ‐1.08– ‐0.38) times for EVT. Finally, PSWO did not demonstrate significant improvements in rates of good functional outcome (RR=1.04; 95% CI, 0.97–1.12) or mortality at 90 days (RR=1.00; 95% CI, 0.76–1.31).

Conclusions

This systematic review and meta‐analysis found that PSWO significantly improves several time metrics related to stroke treatment leading to improvement in IVT reperfusion rates. Thus, the implementation of these measures in stroke networks is a promising avenue to improve an often‐neglected aspect of the stroke response. However, the limited available data suggest functional outcomes and mortality are not significantly improved by PSWO, hence further studies and improvement strategies vis a vis PSWOs are warranted.

 

Intravenous Thrombolysis in Patients Dependent on the Daily Help of Others Before Stroke

And why pray tell would being dependent on others for your care have anything to do with eligibility for tPA?  This previous criteria should have been massively pushed back on by our incompetent stroke associations. You better hope your hospital has adjusted the tPA protocol before your next stroke if you are already dependent on others.
http://stroke.ahajournals.org/content/early/2016/01/21/STROKEAHA.115.011674.abstract

1. Henrik Gensicke, MD,
2. Daniel Strbian, MD,
3. Sanne M. Zinkstok, MD, PhD,
4. Jan F. Scheitz, MD,
5. Olivier Bill, MD,
6. Christian Hametner, MD,
7. Solène Moulin, MD, MSc,
8. Andrea Zini, MD,
9. Georg Kägi, MD,
10. Alessandro Pezzini, MD,
11. Visnja Padjen, MD, PhD,
12. Yannick Béjot, MD,
13. Sydney Corbiere, MD,
14. Thomas P. Zonneveld, MD,
15. David J. Seiffge, MD,
16. Yvo B. Roos, MD, PhD,
17. Christopher Traenka, MD,
18. Jukka Putaala, MD,
19. Nils Peters, MD,
20. Leo H. Bonati, MD,
21. Sami Curtze, MD, PhD,
22. Hebun Erdur, MD,
23. Gerli Sibolt, MD,
24. Peter Koch, MD,
25. Laura Vandelli, MD,
26. Peter Ringleb, MD,
27. Didier Leys, MD,
28. Charlotte Cordonnier, MD,
29. Patrik Michel, MD,
30. Christian H. Nolte, MD,
31. Philippe A. Lyrer, MD,
32. Turgut Tatlisumak, MD,
33. Paul J. Nederkoorn, MD, PhD,
34. Stefan T. Engelter, MD,
35. for the Thrombolysis in Stroke Patients (TriSP) Collaborators

+ Author Affiliations

1. From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P.K., C.H.N.); Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland (O.B., P.M.); Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (C.H., P.R.); University Lille, Inserm, CHU Lille, U1171-Degenerative and Vascular Cognitive Disorders, Lille, France (S.M., D.L., C.C.); Stroke Unit, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy (A.Z., L.V.); Department of Neurology, Kantonsspital St. Gallen, St Gallen, Switzerland (G.K.); Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy (A.P.); Department of Neurology, Clinical Centre of Serbia, Beograd, Serbia (V.P.); Department of Neurology, University Hospital, and Dijon Stroke Registry, University of Burgundy, Dijon, France (Y.B.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); and Department for Medicine of Aging and Rehabilitation, University Center, Felix Platter Hospital, Basel, Switzerland (S.T.E.).

1. Correspondence to Henrik Gensicke, MD, Department of Neurology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland. E-mail henrik.gensicke@usb.ch

Abstract

Background and Purpose—We compared outcome and complications in patients with stroke treated with intravenous thrombolysis (IVT) who could not live alone without help of another person before stroke (dependent patients) versus independent ones.

Methods—In a multicenter IVT-register–based cohort study, we compared previously dependent (prestroke modified Rankin Scale score, 3–5) versus independent (prestroke modified Rankin Scale score, 0–2) patients. Outcome measures were poor 3-month outcome (not reaching at least prestroke modified Rankin Scale [dependent patients]; modified Rankin Scale score of 3–6 [independent patients]), death, and symptomatic intracranial hemorrhage. Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (OR [95% confidence interval]) were calculated.

Results—Among 7430 IVT-treated patients, 489 (6.6%) were dependent and 6941 (93.4%) were independent. Previous stroke, dementia, heart, and bone diseases were the most common causes of preexisting dependency. Dependent patients were more likely to die (OR_unadjusted, 4.55 [3.74–5.53]; OR_adjusted, 2.19 [1.70–2.84]). Symptomatic intracranial hemorrhage occurred equally frequent (4.8% versus 4.5%). Poor outcome was more frequent in dependent (60.5%) than in independent (39.6%) patients, but the adjusted ORs were similar (OR_adjusted, 0.95 [0.75–1.21]). Among survivors, the proportion of patients with poor outcome did not differ (35.7% versus 31.3%). After adjustment for age and stroke severity, the odds of poor outcome were lower in dependent patients (OR_adjusted, 0.64 [0.49–0.84]).

Conclusions—IVT-treated stroke patients who were dependent on the daily help of others before stroke carry a higher mortality risk than previously independent patients. The risk of symptomatic intracranial hemorrhage and the likelihood of poor outcome were not independently influenced by previous dependency. Among survivors, poor outcome was avoided at least as effectively in previously dependent patients. Thus, withholding IVT in previously dependent patients might not be justified.

Safety of Statin Pretreatment in Intravenous Thrombolysis for Acute Ischemic Stroke

I guess I'm supposed to be smart enough to understand what statin pretreatment is since it is never explained. 

Safety of Statin Pretreatment in Intravenous Thrombolysis for Acute Ischemic Stroke

Tsivgoulis G¹, Kadlecová P², Kobayashi A², Czlonkowska A², Brozman M², Švigelj V², Csiba L², Kõrv J², Demarin V², Vilionskis A², Jatuzis D², Katsanos AH², Rudolf J², Krespi Y², Mikulik R².

Author information

Abstract

BACKGROUND AND PURPOSE:

A recent meta-analysis investigating the association between statins and early outcomes in acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT) indicated that prestroke statin treatment was associated with increased risk of 90-day mortality and symptomatic intracranial hemorrhage. We investigated the potential association of statin pretreatment with early outcomes in a large, international registry of AIS patients treated with IVT.

METHODS:

We analyzed prospectively collected data from the Safe Implementation of Treatments in Stroke-East registry (SITS-EAST) registry on consecutive AIS patients treated with IVT during an 8-year period. Early clinical recovery within 24 hours was defined as reduction in baseline National Institutes of Health Stroke Scale score of ≥10 points. Favorable functional outcome at 3 months was defined as modified Rankin Scale scores of 0 to 1. Symptomatic intracranial hemorrhage was diagnosed using National Institute of Neurological Disorders and Stroke, European-Australasian Acute Stroke Study-II and SITS definitions.

RESULTS:

A total of 1660 AIS patients treated with IVT fulfilled our inclusion criteria. Patients with statin pretreatment (23%) had higher baseline stroke severity compared with cases who had not received any statin at symptom onset. After adjusting for potential confounders, statin pretreatment was not associated with a higher likelihood of symptomatic intracranial hemorrhage defined by any of the 3 definitions. Statin pretreatment was not related to 3-month all-cause mortality (odds ratio, 0.92; 95% confidence interval, 0.57-1.49; P=0.741) or 3-month favorable functional outcome (odds ratio, 0.81; 95% confidence interval, 0.52-1.27; P=0.364). Statin pretreatment was independently associated with a higher odds of early clinical recovery (odds ratio, 1.91; 95% confidence interval, 1.25-2.92; P=0.003).

CONCLUSIONS:

Statin pretreatment seems not to be associated with adverse outcomes in AIS patients treated with IVT. The effect of statin pretreatment on early functional outcomes in thrombolysed AIS patients deserves further investigation.